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CHAPTER 2 Principles of surgery
82
Incisions and closures
Body cavity incisions
General terms are applied to the incisions of access to each body cavity.
Laparotomy.• Any incision accessing the peritoneal cavity or
retroperitoneal space. Separate types of laparotomy are described
according to their location in the abdomen, tissues that are crossed,
or, occasionally, the individual who described them (see Fig. 2.5).
Thoracotomy.• Accessing the chest cavity, typically the pleural space
or posterior mediastinum. Median sternotomy is a particular type of
thoracotomy for access to the anterior and middle mediastinum.
Craniotomy.• Accessing the compartments of the skull.
Incision closures
Incisions in body cavities are generally closed according to some basic
principles.
Fascial layers offer the best tissue to bear the strength of apposition •
and form the main closure in the abdomen. Closure is usually made
with heavyweight non-permanent sutures.
Bony defects, such as in a craniotomy, should be apposed to allow •
minimal movement.
Defects in fascial or bony tissues should be replaced either with •
transposed tissues (e.g. skin, fascial, muscle fl aps) or with inserted
tissues (e.g. synthetic products such as polypropylene mesh)
(see b p. 596).
Large cavities and potential spaces between tissues should be avoided •
to reduce the risk of fl uid collections which run the risk of becoming
infected.
Lanz 4.
B
6
5
4
3
21
7
8
A
1
2
3
4
Fig. 2.5 Incisions. Reproduced with permission from Longmore, M. et al. (2007).
Oxford Handbook of Clinical Medicine, 7th edn. Oxford University Press, Oxford.
1. Kocher
2. Midline
3. Muscle splitting loin (ureter)
4. Pfannenstiel
5. Thoraco-abdominal
(oesophagogastrectomy
9th or 10th intercostal
space)
5
Muscle-cutting traverse 5.
McEvedy (femoral hernia) 7.
Inguinal hernia incision 8.
Paramedian 1.
McBurney 3.
Roof-Top 6.
DRAINS
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Drains
Uses and complications
Drains may be used for several reasons (see also b p. 93).
To remove existing abnormal collections of fl uid, blood, pus, air (e.g. •
drainage of a subphrenic abscess, removal of a pneumothorax).
To prevent the build-up of either normal bodily fl uids (e.g. bile after •
surgery to the bile duct) or potential abnormal fl uids or air (e.g.
bloody fl uid in the pelvis after rectal surgery).
Occasionally used to prevent or ‘warn’ of potentially serious or life-•
threatening complications (e.g. neck drains after thyroid surgery, chest
drains after chest trauma in patients undergoing GA).
Potential complications should be balanced against drain use.
Damage to structures during insertion, even if under CT or ultrasound •
guidance (e.g. risk of injury to spleen in subphrenic abscess drainage,
haemorrhage from abdominal vessels in operative drains).
Drains provide a potential route of introduction of infection, especially •
external drains that remain for longer than a few days.
Damage to structures close to the drain, e.g. pressure injury to bowel •
if subjected to high pressure suction drainage.
Drains do not always drain the substance expected and may give a •
false ‘sense of security’, e.g. failure to drain bleeding after thyroid
surgery or failure to drain faecal fl uid after anastomotic leakage.
There is no place for ‘routine’ use of drains after surgery unless there is a
clear indication—‘Better no drainage than ignorant use of it.’ (Halstead).
Types of drain (see Box 2.4)
Materials used include latex rubber (e.g. T tubes), silastic rubber (e.g.
long-term urinary catheters), polypropylene (e.g. abdominal drains), polyurethane (e.g. NGT).
83
Box 2.4 Types of drains
Open passive drains
These provide a conduit around which secretions may fl ow.
•
Yates corrugated drain (after subcutaneous abscess drainage).
Penrose tube drain.•
Drainage setons placed in anal fi stulas.•
Closed passive drains
These drain fl uid by gravity (‘siphon effect’) or by capillary fl ow.
Robinson tube drain (after intra-abdominal abscess drainage).
•
NGT.•
Ventriculoperitoneal shunt.•
Chest drain (tube thoracostomy).•
Closed active drains
These generate active suction (low or high pressure).
•
Exudrains
pelvic or breast surgery).
®
, Redivac drains®, Minivac®, Jackson Pratt drains (after
CHAPTER 2 Principles of surgery
84
Stomas
Terminology and types
The term stoma is usually applied to an external opening (temporary or
permanent) in a lumenated organ.
Ileostomy.• Formed from any part of the mid- or distal small bowel. May
be loop (often to ‘rest’ the distal bowel) or end (usually as a result of
surgical removal of distal bowel).
• Formed from any part of the large bowel. May be loop (to
Colostomy.
rest distally) or end (because of surgical resection).
Urostomy.• Formed from a short length of disconnected ileum into
which one or both ureters are diverted (usually after radical lower
urinary tract surgery).
Gastrostomy.• Either a surgically created or endoscopically formed
connection between anterior stomach and anterior abdominal wall.
Often for stomach drainage or direct feeding.
Jejunostomy.• Either a surgically created or endoscopically formed
connection between proximal jejunum and anterior abdominal wall.
Often for direct feeding.
Identifying stomas
Any stoma may have many different appearances. Typical features that
help in identifying stomas are the following:
Ileostomies (loop or end) are usually spouted, have prominent •
mucosal folds, tend to be dark pink/red in colour, and are most
common in the right side of the abdomen.
Colostomies (loop or end) are usually fl ush, have fl at mucosal folds, •
tend to be light pink in colour, and are most common in the left side
of the abdomen.
Urostomies (end) are usually spouted, have prominent mucosal folds, •
tend to be dark pink/red in colour, and are most common in the right
side of the abdomen. They are indistinguishable from end ileostomies
unless the output can be seen.
Gastrostomies and jejunostomies are usually narrow calibre, fl ush with •
little visible mucosa, and are most common in the left upper quadrant
of the abdomen. They are usually fi tted with indwelling tubes or access
devices.
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CHAPTER 2 Principles of surgery
86
Knots and sutures
Types of suture
See Fig. 2.6 and Table 2.2.
Non-absorbable sutures tend to be used where any loss of strength •
might compromise the future integrity of the tissues being joined, e.g.
vascular anastomoses, hernia mesh fi xation, tendon repairs, sternal
wiring.
Absorbable sutures tend to be used where the persistence of foreign •
material would cause unnecessary tissue reaction or increased risk of
infection, e.g. bowel anastomoses, skin and subcutaneous tissues.
Monofi laments have the advantage of smooth tissue passage and •
minimal tissue reaction, but tend to have a crystalline structure that
increases the ‘memory’ effect of the suture, making knotting less
secure and increasing the risk of suture ‘fracture’.
Braided polyfi laments exert more tissue friction during the passage •
through, but are intrinsically more fl exible and knot securely more
easily.
Sizes of suture
Size is denoted by imperial sizes from 10/0 (smallest—invisible to naked
eye) through 4/0 (typical size for fi ne vascular anastomoses), 2/0 (typical
size for bowel anastomoses), and 1 (typical size for abdominal closure), to
4 (largest available—size of sternal wires).
Types of needle
Needles may be curved (anything from half round to shallow curved) or
straight.
Blunt-ended, round-bodied• (often used for closing major incisions).
Relatively safe as it has low tissue penetrance.
Round-bodied• (sharp-pointed, but smooth, round, cross-sectional
profi le). ‘Pushes’ tissue apart so often used for delicate tissues such as
bowel, blood vessels, etc.
Cutting point • (sharp point with triangular cross-section giving a specifi c
cutting edge). Slices through tissues so often used for dense structures
such as fascia and tendons (also reverse cutting point).
Table 2.2 Types of suture material
Natural fi bre Synthetic fi bre
Non-absorbable
monofi lament
Non-absorbable
braided polyfi lament
Absorbable
monofi lament
Absorbable braided
polyfi lament
Silver wire Steel wire Polypropylene nylon
Silk (eventually does
decay)
Monocryl® PDS
Vicryl® Dexon
Ethilon
®
®
®
KNOTS AND SUTURES
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Horizontal mattress Subcuticular continuous
dnahrevo suounitnoCtrebmeL detpurretnI
87
Halsted
Figure-of-eight Interrupted
Purse-string
Fig. 2.6 Types of suturing used (illustrated as skin sutures).
CHAPTER 2 Principles of surgery
88
Post-operative management
Routine tests
Protocols vary widely according to the complexity of surgery and the age
of the patient: this is a rough guide to management of the older patient
following major abdominal, cardiac, or reconstructive surgery.
Blood tests FBC and U&E on days 1, 2, and 5. Look for the following.
Anaemia: consider haemodilution or slow surgical bleeding.•
Raised WCC: look for other signs of sepsis (see • b pp. 104, 138).
Monitor INR/clotting daily if the patient is anticoagulated and before •
insertion of drains or central lines.
Check Na•
Monitor urea and creatinine, especially in preoperative renal •
dysfunction, cardiac and aortic surgery, nephrotoxic drugs (e.g.
NSAIDs, ACE-inhibitors, vancomycin/gentamicin, fl uid restriction).
ECG Very rarely used routinely outside post-cardiac surgery. Look for:
rhythm disturbances such as AF or evidence of ischaemia.
CXR
Request daily if chest drains are present on suction, after drain removal,
and to check position of newly placed central lines. Look for:
Position of indwelling lines;
•
Consolidation, pneumothorax (on side of central line), pulmonary •
oedema, pleural effusion.
Ward rounds
See patients once a day (twice if unwell, not progressing as expected, or
undergoing investigations or treatment). In the evening, review the blood
results and other investigations from that day. For formal ward rounds,
do the following:
Make sure you have a nurse with you—the nursing record.
•
Make sure someone writes a summary in the patient’s notes.•
Ask the patient if they are experiencing any problems: establish •
whether they are mobilizing appropriately, eating and drinking, have
adequate pain control, passing urine, and opening bowels.
Check the obs chart for ‘ABCDE’ (oxygen saturations, pulse, and •
BP trends), as well as temperature, fl uid balance, and drainage if
monitored.
Look at exposed wounds for evidence of infection or seromas, but do •
not expose covered wounds.
Check diabetic charts for BS control.•
Review the drug chart. Restart regular oral medication as soon as •
possible. Convert IV to PO where appropriate. Look actively for drugs
that can be discontinued to minimize polypharmacy.
Review the most recent blood results.•
Review the nutritional status of the patient—what is the best route?•
Make a clear problem list and a clear plan.•
+
and K+ to guide choice of crystalloid (see b p. 92).
POST-OPERATIVE MANAGEMENT
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Special cases
Surgery for malignancy
Liaise with specialist nurses; they will know the overall plan from the multidisciplinary team (MDT). Don’t discuss results without consulting them
fi rst. Breaking bad news is discussed on b pp. 4 and 16.
Plastic and reconstructive surgery
•
Check perfusion of fl aps daily.
Check take of split-skin grafts on day 5.•
Book post-operative medical illustration for photos prior to discharge.•
Orthopaedic surgery
Check X-rays of prosthesis to assess position, fraction reduction.
Vascular surgery
Check distal pulses and capillary refi ll in patients after reconstructive
•
surgery.
Perform neurological examination to evaluate patients post-carotid •
endarterectomy.
Arrange prosthesis fi tting for amputees.•
Cardiac surgery
Check sternal stability daily (ask the patient to cough while you feel for •
abnormal sternal movement).
Request transthoracic echo for day 4–5 post-operatively in valve repair •
patients and auscultate daily.
Discharge
Plan discharge from the day of admission. Use the hospital discharge •
team and identify patients requiring special facilities, such as
rehabilitation as soon as possible.
Make sure the patient understands what operation they have had.•
Tell them how to look out for common problems like wound •
infections, what is normal, and who to contact if they are worried.
Tell them when they will be seen in clinic.•
Tell them when they can expect to go back to work.•
Ensure an informative, but concise, discharge summary for the GP •
(see b p. 5).
Rehabilitation
The average times for patients to be fi t to go back to work are as
follows:
•
Two to six weeks after abdominal or thoracic surgery, depending on
size and approach (e.g. laparoscopic or open).
Weight bearing takes up to 2 months after lower limb arthroplasties •
and 3 months after lower limb fractures.
Patients can usually drive once they are fully mobile as long as they •
have not experienced blackouts or fi ts.
There are detailed rules for heavy goods vehicle (HGV) drivers and •
pilots available online.
1
Reference
1 M http://www.dvla.gov.uk/medical.aspx
89
CHAPTER 2 Principles of surgery
90
Drain management
Uses and types of abdominal drains are covered on b p. 83. A summary
follows:
Drains may remove collections of fl uid or gas from body cavities.•
They can be inserted as • prophylaxis or treatment.
Effl uent can be collected in • closed or open containers.
Closed containers may have a • simple or an underwater seal.
Drainage can be • suction or non-suction.
Drains may be made of latex, PVC, polyurethane, or silicone.•
Chest drains
Indications for chest drains and insertion are described on b p. 194.
Chest drainage should always be into an underwater sealed container.
Management of chest drains inserted for pneumothorax
Put the drain on low pressure, high volume wall suction (–3–5kPa) •
initially (not the high pressure wall suction used for tracheal toilet).
Request and review CXRs daily.•
Bubbling in the underwater seal, either continuously or only when •
the patient coughs, indicates an air leak and implies that the lung
parenchyma has not healed. 2 You can only remove the drain when
there is no air leak; otherwise a pneumothorax will rapidly re-form.
When the air leak stops, take the drain off suction for 12h and repeat •
the CXR: if the lung is fully up, the drain can be removed.
Get a CXR after drain removal to check for a pneumothorax.•
Management of chest drains inserted to drain collections
Management of chest trauma is described on b p. 480.
There is no evidence that suction improves outcome.•
Make sure that the nursing staff measures the drainage: hourly in the •
post-operative patient, every 24h in longer-term drains.
•
A haemodynamically unstable post-operative patient or one who is
draining more than 200mL blood/h should be discussed urgently with
the thoracic surgeons.
Post-operative thoracic drains are normally removed when they drain •
nothing for 2 consecutive hours unless there is an air leak.
Drains for pleural effusions can be removed when they drain less than •
250mL in 24h.
Drains for empyemas can be removed when they stop draining.•
Always request and review a CXR after drain removal to check for •
pneumothorax.
DRAIN MANAGEMENT
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Clamping chest drains
Clamping drains when transferring patients stems from the days of TB
treatment with caustic solutions and was aimed to prevent drain effl uent
draining back into the chest. In modern practice, the only indications to
clamp a drain are: (1) in the trauma setting if the patient is exsanguinating
leaks or pneumonectomy.
•
Clamping a thoracic drain in a patient with an air leak may rapidly
result in a tension pneumothorax.
Clamping a mediastinal drain in a patient who is bleeding may rapidly •
result in cardiac tamponade.
The safest mode is an • unclamped drain connected to an underwater
seal that is kept below the level of the patient at all times.
If you connect the drain to wall suction, but do not put the wall •
suction on, this is effectively clamping the drain; if you and the nurses
do not know what you are doing, ask for help.
If you press in the one-way valve on the top of the underwater seal •
too tightly, this effectively clamps the drain. If in doubt, leave it alone!
91
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